Provider Demographics
NPI:1386368850
Name:I AM LIGHT
Entity type:Organization
Organization Name:I AM LIGHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANQUINARTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA ED, NCC
Authorized Official - Phone:910-301-7752
Mailing Address - Street 1:4813 CASTLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-6273
Mailing Address - Country:US
Mailing Address - Phone:910-301-7752
Mailing Address - Fax:
Practice Address - Street 1:4813 CASTLE HILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-6273
Practice Address - Country:US
Practice Address - Phone:910-301-7752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health